In recent years, there have been increasingly aggressive attempts to treat postoperative pain. This trend was instigated, in part, when the Joint Commission on Accreditations of Hospital Organizations (JCAHO) designated pain as the “fifth” vital sign. Unfortunately, as an unintended consequence, more and more patients are being overdosed with narcotics, either from Patient Controlled Analgesia (PCA) devices or via neuraxial narcotics (epidurals). This has resulted in more and more cases of profound respiratory depression, apnea, hypoxemia and brain injury or death. The literature would suggest that between 0.1% and 1% of patients on PCA will have one or more episodes of serious respiratory depression. The Anesthesia Patient Safety Foundation (APSF), which has been recognized as a leader in the field of patient safety by the Institute of Medicine, has identified narcotic-induced postoperative respiratory depression as a major cause of perioperative morbidity. Current monitoring modalities are inadequate to detect and treat the respiratory depression seen in post operative patients. Intermittent nursing assessments, even if done on a frequent basis, are not adequate to detect the rapid onset of airway obstruction, apnea, and hypoxia that can occur in many of these patients. Continuous nursing observation, as in an ICU setting, is cost-prohibitive and simply not practical given the large number of patients at risk.
Currently, there is no good way to detect and treat episodes of postoperative respiratory depression. Even frequent nursing checks (every two hours) are insufficient to detect and treat apnea and hypoxemia in a timely fashion. Patients who are using PCAs that have been set for a 10 minute lockout could administer as many as 12 IV boluses of narcotics to themselves between nursing checks. Continuous monitoring of these patients in ICU settings with 1:1 or 1:2 staffing is simply impractical given the large number of patients who would need monitoring.